Verification Request Form | Verification Request Form

Layout

Contact Information

First and Last Name (as listed on your policy) *

Gender (as listed on your policy) *

Preferred name and/or pronouns (if different than on your policy).

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you the primary account holder? *

Yes
No

Phone *

Email *

Treatment & Concerns

Are you also interested in Acupuncture or Chinese Bodywork/Massage *

Yes
No

Primary Concern

Please list any other concerns you may have or anything else you would like us to know.

Insurance Information

Insurance Company *

For MVAs please list the company that insures your motor vehicle.

Policy ID # (please include alpha prefix if your ID contains one) *

Group #

Attach a photo of the front your insurance card here *

Click or drag files to this area to upload. You can upload up to 2 files.

Attach a photo of the back of your insurance card here (copy) *

Click or drag files to this area to upload. You can upload up to 2 files.

Attach a letter of referral or prescription if required.

Click or drag files to this area to upload. You can upload up to 4 files.

* Some health plans & ALL motor vehicle accident claims require a referral stating medical necessity. i.e., treatment to address a pain or injury complaint by a primary care provider.

For MVAs Only

Is this a claim related to a motor vehicle accident ? *

Yes
No

Policies & Disclaimers

Privacy Policy

The information in this form includes your legally protected health information to be stored securely and kept confidential unless required by law. Your health information will only be shared with the providers involved in your treatment and office staff for the purpose of eligibility or pre-authorization submitted to your insurance company.

Our complete privacy practices and policies are listed online https://bodyawaremassage.com/privacy-policy/ and a written copy can be provided by request.

Today's Date *

By signing below, I consent to my personal health information being collected and stored and that I have been informed of my privacy rights. *

INSURANCE VERIFICATION FORM